Renal Injury After Percutaneous Coronary Intervention

Introduction:

Coronary artery disease is a condition that affects the coronary arteries that supply blood to the heart. In this condition, plaque buildup blocks and narrows more than one artery. This can cause increased chest discomfort and can lead to heart attacks and other complaints like heart failure and arrhythmia. Surgeries can treat this condition. The two main procedures include percutaneous coronary intervention and coronary artery bypass grafting. The below article briefs about the most misdiagnosed complication of percutaneous coronary interventions, the renal injury.

What Is a Percutaneous Coronary Intervention (PCI)?

Percutaneous coronary intervention is the treatment done to open a blocked artery. The arteries are the blood vessels that carry oxygen-rich blood through the body. Percutaneous coronary intervention is needed if the arteries have fatty buildup and waxy substances.

• Percutaneous coronary intervention is done to clear blockages after a heart attack. It is also known as coronary angioplasty.

• It is a minimally invasive procedure and can be done with a stent. In this procedure, a small balloon reopens the blocked artery to increase blood flow.

• A cardiologist places a small stent (permanent tube) that keeps the artery open for the long term. This stent usually contains medications that release directly into the artery and reduces the risk of re-narrowing within the stent.

What Are the Indications of Percutaneous Coronary Intervention?

Percutaneous coronary intervention is the procedure to remove plaque buildup from the arteries. This plaque buildup results in the hardening of the arteries, known as atherosclerosis. Atherosclerosis increases the risk of cardiovascular disease and blocks the blood flow through the heart, and if the heart fails to pump blood efficiently, chest pain can be felt. Therefore, percutaneous coronary intervention is the primary treatment for heart attacks. This procedure opens the blood vessels and helps minimize heart damage.

What Are the Contraindications of Percutaneous Coronary Intervention?

Percutaneous coronary intervention, medical therapy, and coronary artery bypass graft surgery usually depend on several factors, and if the factors do not fit the criteria applicable, the surgery is contraindicated. The factors are:

• Number and characteristics of the blockages present.

• Heart muscle function and age.

• Cardiac and noncardiac medical conditions.

What Is Renal Injury After the Percutaneous Coronary Intervention?

Acute kidney injury is defined as a 0.3 mg/dl increase from the reference value within 48 hours or a 1.5-fold relative elevation in blood creatinine within seven days from a reference value established 30 days before PCI. A serious complication is associated with an increased risk of dialysis, myocardial infarction, and death. Renal injury post percutaneous coronary intervention shows initial worsening of renal function, with clinical manifestation that ranges from a minimal increase in serum creatinine to anuric renal failure that requires renal replacement therapy. An acute injury that frequently co-exists with acute coronary syndrome due to hemodynamic instability by often precipitating factors that can improve percutaneous coronary intervention.

What Are the Risk Factors for Getting Renal Injury After Percutaneous Coronary Intervention?

There are many independent predictors of acute renal failure and dialysis, each risk factor with many contributors. The risk factors are best classified into modifiable and non-modifiable risk factors. Modifiable risk factors are for the individuals or procedure-related.

Non-Modifiable Risk Factors:

• Age: Advance age is the main risk factor for getting a renal injury.

• Diabetes Mellitus: Diabetes is another risk factor for the development of acute renal injury that also leads to the need for dialysis. Diabetes and chronic renal injury appear to act synergistically.

• Cardiac Risk Factors: Acute decompensated heart failure, cardiogenic shock, and acute coronary syndrome are associated with an increased risk of acute kidney failure.

• Chronic Kidney Disease: Pre-existing chronic kidney disease is the most important risk factor for renal injury post-percutaneous coronary intervention.

Individual-Related Modifiable Risk Factors:

• Anemia: Individuals with chronic kidney disease are more likely to worsen the renal injury. The incidence is higher in anemic individuals than in non-anemic individuals.

• Volume Depletion and Hemodynamic Instability: Volume depletion occurs when sodium-containing fluids are lost in the urine from the gastrointestinal tract or skin or by acute sequestration. Hemodynamic instability occurs when there is abnormal or unstable blood pressure that causes inadequate blood flow.

• Nephrotoxicity Drug Use: Concomitant use of nephrotoxic agents like NSAIDs like Tacrolimus, Cyclosporine, and diuretics increases the risk of renal injury by interfering with the autoregulatory responses of renal circulation.

Procedure-Related Modifiable Risk Factors:

• Timing of Angiography and Urgency of the Procedure: The timing of the renal injury is related to contrast exposure and plays an important role in developing acute renal failure. Individuals who undergo coronary artery bypass surgery within one day of coronary angiography have an approximately twofold increase in the risk of major adverse renal and cardiac events compared with those who waited more than five days.

• The Osmolality of Contrast Media: Acute renal injury increases with high osmolar contrast use in individuals with chronic kidney disease.

• The Volume of Contrast Media: Higher volume contrast use significantly increases the risk of acute renal injury. A creatinine clearance ratio of more than two is an independent predictor of individuals with renal injury.

• Hemodynamic Support: Value of mechanical circulatory support in reducing the risk of acute kidney injury in hemodynamically unstable individuals. The use of left ventricular assist devices, mainly Impella, to maintain hemodynamic stability and end-organ perfusion has a role in reducing acute kidney injury.

Conclusion:

Many acute coronary syndrome patients with elevated baseline serum creatinine values show stabilization and improvement in serum creatinine values rather than worsening after successful percutaneous coronary intervention. However, all patients with impaired basal serum creatinine show worsening renal function post-percutaneous coronary intervention. Individuals with radial access suffered less acute kidney injury. In most cases, the access site is not independently associated with a lower incidence of acute kidney injury in individuals with myocardial infarction in non-matched and matched cohorts. The results suggest a lower incidence of acute kidney failure in individuals with radial access in unmatched cohorts, at least influenced by confounding factors, mainly bleeding. The overall incidence of renal injury after a percutaneous coronary intervention is low. Still, the risk factors increase the risk of renal injury and short or long-term mortality.